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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> 03/2017 rp www.water.state.co.us and dwermitsonline@state.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells, monitoring and other holes. Type <br /> or print in black or blue ink. Instructions and plugging standards are on reverse side <br /> 1. Well Permit Number of plugged well or MH File Number MH- <br /> Owners Well Designation- Receipt Number: <br /> 2. Individual/Company responsible for plugging and sealing the well: <br /> Name(s) License# <br /> Mailing Address <br /> City, St., Zip <br /> Phone Email <br /> 3. Well (Hole)Owner: Name(s): <br /> Phone: ( ) _Email: <br /> Mailing Address, City, St., Zip: <br /> 4. Well Location Address: <br /> 5. GPS Well Location: County <br /> UTM []Zone 12 or []Zone 13 Easting Northing <br /> 6. Legal Location: _1/4 of the_ 1/4, Sec , Twp ❑N or S❑, Range ❑E or W Q P.M. <br /> Distance from Section Lines Ft. From EL N or S Ft. From -0 E or W]a Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on (date) for the following reason(s): <br /> ❑The well was plugged and sealed as required under Well Permit Number <br /> ❑The well was not in use and was plugged and sealed. <br /> ❑Other (please explain) <br /> 8. Aquifer Type: p Type I (One Confining Layer) ©Type I (Multiple Confining Layer) p Laramie-Fox Hills <br /> (check one) E3 Type II (Not Overlain by Type III) E3 Type II (Overlain by Type III 0 Type III (alluvial) <br /> 9. Intervals of Casing Removed/Ripped: <br /> from feet to feet, from feet to feet, from feet to feet, <br /> from feet to feet, from _feet to feet, from feet to feet, <br /> 10. Amount and Type of Material Method of Placement Interval <br /> from feet to feet <br /> from feet to feet <br /> from feet to feet <br /> from feet to feet <br /> I have read the statements made herein and know the contents thereof,and they are true to my knowledge. This document is signed(or name entered <br /> if filing online)and certified in accordance with Rule 17.4 of the Water Well Construction Rules,2 CCR 402 2. The filing of a document that contains <br /> false statements is a violation of section 37 91 108(1)(e),C.R.S.,and is punishable by fines up to$1,000 and/or revocation of the contracting license. If <br /> filino nnlinP the States FnoinPPr rnnciriPrc the Pntry of the IirPnCPri rnntrartnr'c names to hp in romnlianrP with RIIIP 17 4 <br /> 11. Signature(s) Please Print the Name, Title, Et License No. Date <br /> It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor is <br /> responsible for notifying the owner of this requirement in writing. <br />